연하빈맥 ( Deglutational Arrhythmia ) 의 기전과 치료에 관한 고찰 증례보고를 통해

이천균(Chun Kyon Lee),전동운(Dong Woon Jun),박종석(Jong Suk Park),최동훈(Dong Hun Choi),홍범기(Bum Ki Hong),김성순(Sung Soon Kim) 대한내과학회 1996 대한내과학회지 Vol.51 No.5

Deglutition arrhythmia is a rare disease entity. We experienced atrial tachyarrhythmia associated with degllutition in a 70-year-old male patient who previously underwent DC modification of AV node for the treatment of AV nodal reentrant tachycardia. Electrophysiologic study was performed to delineate the mechanism of atrial tachyarrhythmia. Also the swallowing and the esophageal ballooning reproduced clinically documented atrial tachyarrhythmia and AV nodal reentrant tachycardia. Subsequentyl patient was successfully treated with oral flecainide.

입원환자의 낙상 실태 및 위험요인 조사연구

윤수진,이천균,진인선,강중구,Yoon, Soo-Jin,Lee, Chun-Kyon,Jin, In-Sun,Kang, Jung-Gu 한국의료질향상학회 2018 한국의료질향상학회지 Vol.24 No.2

Purpose: The objective of this study was to report the incidence of falls in hospitals and analyze the risk factors for falls. Methods: This study used data on 1,216 patients who experienced falls from 2015 to 2017 during their hospitalization. The data was collected from the falls incident reports and patient' electronic medical record of hospital. Data were analyzed with descriptive statistics using Chi-square test, Fisher's exact test and multiple Poisson regression analysis with the SAS 9.4 Results: The incidence of falls was 1.38 per 1,000 patients days (2015), 1.81 per 1,000patients days (2016) and 1.99 per 1,000patients days (2017). The incidence of injury caused by falls (level III~V) was 0.05 per 1,000patients days (2015), 0.04 per 1,000patients days (2016) and 0.06 per 1,000patients days (2017). The largest number of falls occurred during night shift (42.5%), specifically in the patients' room (70.8%), and medical unit (66.0%). Average age of fallers was 69.1 years and 61.7% of them were older than 71 years. CCI and the patient's department have statistically significant differences in injury or injury levels from falls, but the integrated nursing care services had no significant difference in injury or injury levels from falls. Conclusion: The result of this study can be used as a reference for establishing a fall prevention strategy for hospitalized patients by presenting index values such as the fall rate.

한국인에서 B 형 간염 바이러스 감염상태와 HLA - DR type 과의 연관성

안상훈(Sang Hoon Ahn),한광협(Kwang Hyub Han),이천균(Chun Kyon Lee),김동기(Dong Kee Kim),강신욱(Shin Wook Kang),전재윤(Chae Yoon Chon),문영명(Young Myoung Moon),박기일(Ki Il Park) 대한내과학회 1998 대한내과학회지 Vol.55 No.1

Objectives : The course after hepatitis B virus infection appears not to be related to variations in virulence of the HBV itself and may be influenced by the host immune response, which in turn may be regulated by the major histocompatibility complex. The purpose of this study was to determine whether the clearance of HBV was related to a particular HI& allele in Korean. Methods : We studied total 1372 Korean persons who had visited Yonsei University Medical Center for renal transplantation from January in 1990 to August in 1997. Hepatitis B-virel markers and HLA-DB types were examined by retrospective study. Results . 1) Among 1372 subjects, 924 were male and 448 were female(Mean age, M:37.4yrs, F:38.3yrs). Healthy donors in total subjects were 424. 2) Commonly, HLA-DR4 was most frequent among the total subjects, also in the group of Non-Exposure, Chronic Carrier, Clearance, and Antibody. 3) HLA-DR6 was significantly frequent in the group of Clearance and Antibody compared with the group of Chronic Carrier(p<0.001, RR=3.72 and p<0.001, RR=3.58, respectively). HLA-DR9 was significantly frequent in the group of Chronic Carrier compared with the group of Clearance and Antibody(p<0.001, BR=3.33 and p<0.001, RB=3.32). Results in healthy donors were same as above. 4) HLA-DR13 was significant between the HLA-DR6 subgroups(DB13, DR14! which may influence the clearance of HRU. Conclusion: HLA-DR6(esp, HLA-DR13) may be associated with elimination of HBV as one of the host factors influencing the immune response to HBV and HLA-DR9 with persistent HBV infection.

만성 B형 간염 치료에 있어 엔테카비어, 클레부딘의 효과비교

김동환 ( Dong Hwan Kim ),김선혜 ( Sun Hye Kim ),김정호 ( Jeong Ho Kim ),박병규 ( Byung Kyu Park ),서정훈 ( Jeong Hun Suh ),조용석 ( Yong Suk Cho ),최종원 ( Jong Won Choi ),이천균 ( Chun Kyon Lee ) 대한내과학회 2010 대한내과학회지 Vol.78 No.5

Background/Aims: Entecavir (ETV) and clevudine (CLV) are potent inhibitors of hepatitis B virus (HBV) DNA polymerase and have demonstrated clinical efficacy. No comparative study has reported on these two medications among patients with na?ve chronic hepatitis B (CHB). We assessed the clinical outcome of CHB patients treated with either ETV or CLV. Methods: A nonrandomized comparative study was conducted retrospectively. The clinical results from treatments of either 0.5mg ETV (n=56) or 30mg CLV (n=45) were analyzed during a 1 year period. The median reduction in serum HBV DNA, undetectable HBV DNA, HBeAg seroconversion, and normalization of alanine transaminase (ALT) were compared between the two groups. Results: After 1 year on antiviral therapy, the median reduction in serum HBV DNA from baseline to the endpoint was greater in patients in the ETV group than in those in the CLV (5.73 vs. 4.5 log copies/mL, p=0.009) group. ALT normalization occurred in 85.5% (47/55) of the ETV cases and 77.3% (34/40) of the CLV cases (p=0.215). HBV DNA was undetectable in 80.0% (44/55) of the ETV group and 78.0% (32/41) of the CLV group (p=0.505). HBeAg seroconversion occurred in 15.4% (6/39) of those administered ETV and in 14.3% (4/28) administered CLV (p=0.593). Within 12 months, a virological breakthrough was documented in three patients undergoing CLV treatment, and CLV-related myopathy developed in three other patients. Conclusions: ETV and CLV showed excellent antiviral effects in patients with CHB. ETV was superior for viral suppression and showed fewer side effects than CLV. (Korean J Med 78:595-601, 2010)

급성 악화를 보인 만성 B형 간염의 치료에 있어서 Lamivudine 즉시 투여의 적절성

이천균,서정훈,조용석,원선영,박인서 대한간학회 2004 Clinical and Molecular Hepatology(대한간학회지) Vol.10 No.1

목적: 만성 B형 간염의 급성 악화시 즉시 라미부딘 치료를 하는 것이 합리적인지에 대해 이해가 부족한 바, 이들의 자연경과를 알아보고 라미부딘 투여군의 비교를 통해서 라미부딘 치료의 적절한 시점을 알아보고자 하였다. 대상과 방법: 2000년 3월부터 2003년 5월까지 본원에 내원한 만성 B형 간염 환자 중 혈중 HBV DNA 또는 HBeAg 양성, ALT>400 IU/L인 35명을 대상으로 혈청 HBV DNA, HBeAg, anti-HBe, ALT를 포함한 간기능 검사를 1-3개월 간격으로 측정하였으며 ALT가 재상승한 경우, 100 IU/L 이상시 라미부딘 100 ㎎을 매일 경구 투여하고, 무작위로 선출된 환자에게 내원 당시 즉시 라미부딘을 투여하고 상기의 방법으로 검사를 시행하여 라미부딘의 효과를 비교하였다. 결과: 내원 당시 혈청 ALT가 400 IU/L 이상의 소견을 보인 27명의 환자를 대상으로 항바이러스제를 투여하지 않고 경과 관찰을 시행하였으며 이중 5명의 환자에게서 평균 19개월 추적관찰중 정상 ALT, HBeAg의 음성, HBV DNA의 음성상태가 유지되었고(제1a군) 3명의 환자에서 ALT가 약간 상승하거나 정상이었지만 HBeAg의 자연 음전은 유도되지 않았다(제1b군). 반면, 19명의 환자에서는 평균 5개월 만에 ALT의 재상승 소견을 보여 라미부딘 치료를 시작하였다(제2군). 제1a군과 제2군 사이에서 혈청 HBV DNA의 중앙값은 각각 6.5 pg/mL과 518.1 pg/mL로 제1a군에서 현저히 낮았으며 HBV DNA가 20 pg/mL 이하였던 환자 7명 중 5명(71.4%)에서 자연음전이 유도되었다. 경과 관찰 중 재상승한 환자 19명 중 16명의 환자와 급성 악화로 내원 즉시 라미부딘을 투여한 환자 8명(제3군)을 비교한 결과, 제2군에서는 3군에 비해 치료시 혈청 ALT는 낮고 HBV DNA는 높았으며 첫 내원시보다 오히려 혈중 HBV DNA가 높은 상태에서 라미부딘 치료가 시작되었다. 양군 간의 라미부딘 치료 효과는 2군에서 56.3% (9/16)로 3군의 62.5% (5/8)와 차이가 없었다. 결론: 급성 악화를 동반한 만성 B형 간염 환자의 경우 내원 당시 혈중 HBV DNA가 현저히 낮은 경우는 HBeAg의 자연음전을 기대할 수 있으나, 대부분의 경우 라미부딘의 즉시 치료를 통한 HBeAg의 음전을 시도하는 것이 바람직하다고 생각된다. Background/Aims: It has been unclear whether immediate antiviral therapy or observation under the expectation of spontaneous inactivation of hepatitis B virus (HBV), is more appropriate for the treatment of chronic hepatitis B (CHB) with acute exacerbation. We intended to analyze the short-term natural course of CHB with acute exacerbation and evaluate the efficacy of lamivudine. Methods: We analyzed 35 CHB patients with acute exacerbation (positive HBV DNA or HBeAg and ALT>400 IU/L) between March 2000 and May 2003. We regularly checked serum HBV DNA, HBeAg and liver unction tests including ALT every 1 to 3 months. If ALT was above 100 IU/L during the follow-up period, patients were treated with 100 ㎎ lamivudine orally once a day. We compared the efficacy of lamivudine use between this group and the group provided with immediate lamivudine trial at their first visit. Results: 27 CHB patients with acute exacerbation were observed without immediate lamivudine trial. In 5 of these patients normal ALT, negative HBeAg and HBV DNA were maintained during 19 months (group la). Slightly elevated or normal ALT was maintained without HBeAg seroconversion in 3 patients (group 1b). However, serum ALT flared up above 100 IU/L in 19 patients within 5 months. So, lamivudine was tried on these patients (group 2). The serum HBV DNA was extremely low, being 6.5 pg/mL in group la compared to 518.1 pg/mL in group 2. Spontaneous inactivation of HBV was observed in 71.4% (5/7) of patients with HBV DNA less than 20 pg/mL at the first visit. ALT was lower and HBV DNA was higher in group 2 than the 8 patients who received immediate lamivudine trial at the first visit (group 3). The response rate of lamivudine was similar between group 2, 56.3% (9/16) and group 3, 62.5% (5/8). Conclusions: Spontaneous inactivation of HBV was expected in CHB with acute exacerbation and extremely low level of HBV DNA (less than 20 pg/mL) in a short term follow-up period. Immediate lamivudine therapy might be more appropriate in most CHB patients with acute exacerbation.(Korean J Hepatol 2004;10:22-30)

소화관 내시경 검사에 의한 감염

이천균,박인서 한국의학사 1997 診斷과治療 Vol.17 No.4

만성 B형 간염에서 B형 간염 바이러스 특이 CD8^+ 림프구의 Chemokine 수용체 발현

이천균,서정훈,조용석,한광협,정재복,전재윤,문영명 대한간학회 2002 Clinical and Molecular Hepatology(대한간학회지) Vol.8 No.4

목적: B형 간염의 조절에 있어서 HBV 특이 CD8+ 림프구는 매우 중요한 역할을 하며 이 세포가 제 역할을 하기 위해서는 감염된 간으로 효율적으로 이동하는 것이 선행되어야 한다. 이 세포가 간으로 적절히 이동하기 위하여 세포에 발현하는 che- mokine 수용체의 발현양상이 중요하며 이에 HBV 특이 CD8+ 림프구의 Chemokine 수용체 발현양상을 알아보고자 하였다. 대상과 방법: HLA-A2 선 별검사를 통해 양성으로 판정된 만성 간염 환자 6명 을 대상으로 혈중 및 간내 림프구를 분리한 후 서로 다른 형광물질이 결합된 Tc 18-27, CD8, CCR3, CCR5로 처리후 유속세포 분석기로 분석하였다. 한편, 이들 세포에서의 바이러스 증식에 따른 chemo- kine수용체 발현의 변화를 알아보고자 in vitro에서 core 18-27 펩타이드로 자극후 동일한 분석을 시행하였다. 결과: Tc 18-27 염색을 통해 4명의 환자에서 충분한 수의 Tc 18-27 특이 CD8+ 림프구를 확인할 수 있었으며 4명은 모두 혈중 HBV-DNA가 0.5pg/mL이하, ALT가 40U/L이하로 바이러스 증식이 멈추고 간염이 호전되는 잠복기 (latent phase) 환자였다. 환자의 혈중 Tc18-27 특이 CD8+ 림프구 의 14-35%에서 CCR5가 발현하였으며 CCR3의 발현은 관찰되지 않았다. 상기 4명의 환자중 3명에서 간조직을 구할 수 있었는데 간내 Tc18-27 특이 CD8+ 림프구의 경우 CCR5는 많게 80%까지 발현한 반면, CCR3의 발현은 약 10%에서만이 관찰되었다. In vitro에서 core 18-27 펩타이드로 자극한 후 분석에서는 CCR5의 경우 72-90%의 세포에서 발현하여 발현의 정도가 간내세포에 준할 정도로 증가하였으나 CCR3의 발현 증가는 관찰되지 않았다. 결론: 이상으로 만성 B형 간염환자라 하더라도 비증식군에서는 바이러스 증식조절에 필요한 chemokine 수용체를 발현하고 있으며 바이러스의 양적 증가시 혈액에서 간으로의 이동이 보다 원활하게 될 수 있도록 적절한 수용체를 증가시킬 수 있는 능력을 유지함을 확인할 수 있었다. Background/Aims: The protective role of HBV-specific CD8+ cells is dependent on their ability to efficiently migrate to the infected liver, where they may exert an effector function. The migratory behavior of CD8+ cells is influenced by their expression of different chemokine receptors. This study was intended to analyse the pattern of chemokine receptor expression of HBV specific CD 8+ cells in chronic B viral infection. Methods: We analysed the CCR5 and CCR3 profile of HBV-specific CD8+ cells isolated from the blood and liver of patients with different patterns of HBV infection. Purified T cells were stained directly ex vivo, or after antigen-specific stimulation, using HBV peptide-specific HLA tetramers and monoclonal antibodies to CD8, CCR5 and CCR3, with analysis by flow cytometry. Results: In patients with chronic hepatitis B characterised by low levels of virus (serum HBV DNA <0.5pg/mL) and minimal liver inflammation, analysis of circulating and intrahepatic CD8+ cells demonstrated that liver infiltrating Tc18-27-specific cells were preferentially CCR5+ (up to 80% of HBV-specific CD8+ cells), in contrast to cells of the same specificity within the circulating compartment (up to 35% of HBV-specific CD8+ cells). Furthermore, CCR3 was expressed by about 10% of Tc18-27+ cells infiltrating the liver, but was absent from circulating cells. Following HBV-specific stimulation in vitro the CCR5 expression of circulating Tc18-27-specific cells was up-regulated, to levels found in liver infiltrating cells, whereas CCR3 expression was unchanged. Conclusions: The chemokine receptor profile of HBV-specific CD8+ cells is influenced by the anatomical site of these cells, and the clinical pattern of disease. The ability of circulating HBV-specific CD8+ cells of patients with low replicating virus to upregulate CCR5 suggests that these cells may respond to increases in virus replication by efficiently migrating into the infected liver.(Korean J Hepatol 2002;8:363-370)

내시경적 유두괄약근절개술의 조기합병증 및 위험인자에 관한 연구

이천균,송시영,이루다,정재복,강진경,김원호,문영명,박인서 大韓消化器病學會 1997 大韓消化器病學會誌 Vol.30 No.6

만성 B 형 간염에서 HLA A2/core 18-27 tetramer 복합체를 이용한 B형 간염바이러스 특이 CD8+ 림프구의 분석

이천균,서정훈,조용석,한광협,정재복,전재윤,문영명 대한간학회 2002 Clinical and Molecular Hepatology(대한간학회지) Vol.8 No.2

목적 : HBV의 조절 및 간세포 손상에 있어 HBV 특이 세포독성 T 림프구가 중요한 역할을 하는 것으로 보고되고 있다. 이에 본 연구에서는 tetramer 분석방법을 통하여 만성 B형 간염의 혈액과 간에서 HBV 특이 세포독성 T 림프구를 측정할 수 있는지를 알아보고 이를 기초로 HBV 특이 세포 독성 T 림프구의 간내침윤 유무를 규명하고 HBV 특이 세포독성 T 림프구와 바이러스 증식여부, 간세포 손상 정도를 비교하고자 하였다. 대상과 방법 : 33명의 HLA-A2 양성 및 8명의 HLA-A2 음성, 만성 B형 간염 환자의 혈액으로부터 단핵구를 분리하여 anti-CD8 항체와 tetrameric HLA-A2/core 18-27 복합체를 이용하여 혈중 core 18-27 특이 CD8+ 림프구를 측정하였으며 이중 11명의 HLA-A2 양성 및 8명의 HLA-A2 음성 환자에서 간내 core 18-27 특이 CD8+ 림프구를 측정하였다. 환자의 혈중 HBV-DNA와 ALT치를 측정하여 이들과 core 18-27 특이 CD8+ 림프구의 빈도를 비교하였다. 결과 : 33명의 HLA-A2 양성 환자중 14명의 혈중에서 50,000개의 CD8+ 세포중 9-101개의 tetramer 특이 세포가 관찰되었으며 간내 단핵구의 분석이 가능하였던 11명의 HLA-A2 양성 환자중 8명의 환자에서 50,000개의 CD8+ 세포중 121-2100개의 core 18-27 특이 CD8+ 세포가 관찰되었고 8명의 환자 모두에서 간내 tetramer 특이 세포의 빈도가 혈중에 비해 17.4-150배 이상 높았다. 혈중 HBV-DNA가 0.5 pg/mL 이하, 혈중 ALT가 40 IU/L 이하였던 18명의 환자중 10명의 혈액에서 tertramer특이 세포가 증가되어 있었으나 혈중 HBV-DNA가 800 pg/mL 이상, 혈중 ALT가 70 IU/L 이상이었던 15명의 환자에서는 4명에서만 tertramer특이 세포의 증가가 관찰되었다. 간내 T c18-27 특이 세포의 빈도는 혈중 HBV-DNA나 혈중 ALT의 상승 정도와는 상관 관계가 없었다. 그러나 간내 T c18-27 특이 세포의 빈도가 높은 3명의 환자는 모두 혈중 HBV-DNA가 낮았으며 혈중 ALT는 정상이었다. 결론 : 본 연구에서는 혈중과 간내 HBV 특이 세포독성 T 림프구를 직접 측정함으로써 만성간염에서도 상당량의 HBV 특이 세포독성 T 림프구가 존재함을 알 수 있었으며, 바이러스가 조절되고 간세포 손상이 뚜렷치 않은 환자에서 활발한 HBV 특이 세포독성 T 림프구의 작용을 관찰함으로써 바이러스의 조절과 간세포 손상은 서로 다른 기전에 의해 이루어지는 것으로 추정된다. Backgrounds/Aims: Hepatitis B virus(HBV) specific cytotoxic T lymphocyte (CTL) response is believed to play a major role in virus control and liver damage in chronic hepatitis B(CHB). We performed this study to evaluate whether HBV specific CTL could be visualized directly by tetrameric HLA-A2/core 18-27 complex(Tc18-27) in the peripheral blood and liver of patients with CHB. On the basis of our results we clarified patients intrahepatic compartmentalization and correlation with HBV specific CTL and viral replication or liver damage. Methods: We stained peripheral blood mononuclear cells of 33 HLA-A2 + and 8 HLA-A2 patients with CHB with cychrome conjugated anti-CD8 mAb and phycoerythrin conjugated T c18-27. Among these we analysed intrahepatic lymphocyte of 11 HLA-A2 + patients. We compared the frequency of T c18-27 specific CD8+ cells with serum HBV-DNA levels or alanine aminotransferase(ALT) levels. Results: The frequency of circulating T c18-27 specific CD8+ cell was higher(9-101 cells per 50,000 CD8+ cells) than background level in 14 among 33 patients. The frequency of intrahepatic T c18-27 specific CD8+ cells was 12-2100 cells per 50,000 CD8+ cells in 8 out of 11 patients whose liver was obtained This was 17.4-150 times higher than circulating T c18-27 specific CD8+ cells. The frequency of circulating T c18-27 specific CD8+ cells was increased in 10 out of 18 patients with serum HBV DNA level <0.5 pg/mL and ALT < 40 IU/L. It was increased in just 4 out of 15 patients with HBV DNA level > 800 pg/mL and ALT >70 IU/L. The frequency of intrahepatic T c18-27 CTL tended to be lower in high levels of serum HBV DNA and was not correlated with liver inflammation. Conclusion: This study provess that if HBV-specific CTLs are barely detectable in the peripheral blood of CHB, much more HBV-specific CTLs are in the liver and most HBV-specific CTLs are infiltrated in the liver. Also, in the presence of an effective HBV specific CD8 response the inhibition of viral replication can be independent of liver damage.(Korean J Hepatol 002;8:139-148)

식도근절개술로 치료한 식도이완불능증에서 발생한 Barrett 식도궤양 1예

박효진,박인서,이천균,송준현 대한소화기내시경학회 1995 Clinical Endoscopy Vol.15 No.3

We report a patient who developed a Barrett,s esophageal ulcer 10 years after esophagomyotomy for achalasia. A-59-year-old female was admitted to the hospital with dysphagia for 2 months. In 1982, she had undergone a modified Heller esophagomyotomy for achalsia. After esophagogram, esophageal manometry, 24hr esophageal pH monitoring, esophagoscophy achalasia and Barrett,s esophageal ulcer was diagnosed. So, she had been treated with omeprazole and sucralfate and has been followed up in a asymtomatic state currently. In Barrett,s esophagus, there is a metaplasia of the normal stratified squamous mucosa to columnar epithelium, caused by the reflux of acid. It appears in approximately 10% of patients with chronic gastroesophageal reflux and is associated with increased probability of adenocarcinoma of the esophagus. Among the predis- posing factors of gastroesophageal reflux, there is treatment of esophageal achalsia by forceful dilatation or by the esophagomyotomy. The resultant ralaxation of lower esophageal sphinter, combined with deficient propulsive esophageal peristalsis, predisposed to gastroesophageal reflux. Actually an increased incidence of gastroesophageal reflux, esophagitis and stricture are well-known complications after esophagomyotomy. But in spite of higher risk of gastroesophageal reflux after esophagomyotomy the development of Barrett,s mucosa has been rarely reported and only recently recognized. Diagnosis of Barrett,s esophagus in such patients is difficult and the cumulative effects of achalasia and Barrett's esophagus predispose these patient to higher risk of developing esophageal carcinoma. So, high index of awareness and regular endoscopic surveillance are required.